Impact of obstructive sleep apnea in cardiovascular risk in the pediatric population: A systematic review

While the association of obstructive sleep apnea (OSA) with an increased cardiovascular risk (CVR) in the adult population is well known, there is insufficient evidence to affirm something similar in the pediatric population. On the other hand, adenotonsillectomy has been shown to be an effective treatment. Our objective was to evaluate the association of sleep respiratory disorders in children with increased CVR and the impact of adenotonsillectomy in the literature. To this aim, a literature search was conducted, between 2002 to the present. After carrying out a systematic review, the following results were provided: thoracic echocardiography after surgery found improvements in terms of cardiac function and structure; blood pressure (BP) measurement, verified a tendency to higher BP values in the OSA pediatric population, which improved after surgery; different biomarkers of CVR, were increased in OSA patients and improved after treatment and finally; some studies found endothelial dysfunction in pediatric OSA, a measurement of vascular system function, was reversible with adenotonsillectomy. Increases in BP parameters, biological markers related to CVR and alterations in cardiac function structure, have been reported in pediatric patients with OSA. At least, some of these parameters would be reversible after adenotonsillectomy, reflecting a possible reduction in CVR.

Effectiveness and safety of (adeno) tonsillectomy for pediatric obstructive sleep apnea in different age groups: A systematic review and meta-analysis

This meta-analysis aimed to assess the effectiveness and safety of (adeno)tonsillectomy (AT) for uncomplicated pediatric obstructive sleep apnea (OSA) across different age groups. Four electronic databases were searched until April 2022, and 93 studies (9087 participants) were selected, including before-after studies, cohort studies, and randomized controlled trials. It has been suggested that age, disease severity, and length of follow-up are associated with surgical effects. Compared with older children (>7 years), patients receiving AT surgery before the age of 7 exhibited a significantly greater release of disease severity, as well as a greater decrease in hypoxemic burden, improvement in sleep quality, and better cardiovascular function. Cognitive/behavioral performance also improved after AT, although it was more related to the length of follow-up than the age at surgery. Notably, the surgical complication rate was considerably higher in patients younger than 3 years old. Overall, we suggest that the age of 3-7 years might be optimal for AT in polysomnography-diagnosed uncomplicated OSA to maximize potential benefits for both disease and comorbidities and balance the risks of surgery.

Effect of surgical intervention for childhood OSA on blood pressure: A randomized controlled study

OBJECTIVE

To investigate the effect of surgical intervention on 24-h ABP in children with OSA. It was hypothesized that blood pressure would improve following adenotonsillectomy.

METHODS

This was a two-centered investigator-blinded randomized controlled trial. Non-obese pre-pubertal children aged 6-11 years with OSA (obstructive apnea-hypopnea index, OAHI >3/h) underwent 24-h ABP monitoring at baseline and 9 months after the randomly assigned intervention, i.e. Early Surgery (ES) or Watchful Waiting (WW). Intention-to-treat analysis was performed.

RESULTS

137 subjects were randomized. Sixty-two (Age: 7.9y ± 1.3, 71% boys) and 47 (Age: 8.5y ± 1.6, 77% boys) participants from the ES and WW groups, respectively completed the study. Changes in ABP parameters were similar in the ES and WW groups (nighttime systolic BP z-scores: +0.03 ± 0.93 vs. -0.06 ± 1.04, p = 0.65; nighttime diastolic BP z-scores: -0.20 ± 0.95 vs. -0.02 ± 1.00, p = 0.35) despite a greater improvement in OSA in the ES group. However, a reduction in nighttime diastolic BP z-score correlated with improvements in OSA severity indexes (r = 0.21-0.22, p < 0.05), and a significant improvement in nighttime diastolic BP z-score [-0.43 ± 1.01, p = 0.027] following surgery was observed in participants with severe preoperative OSA (OAHI ≥10/h). The ES group had a significant increase in body mass index z-score after surgery [+0.27 ± 0.57, p < 0.001], which correlated with the increase in daytime systolic BP z-score (r = 0.2, p < 0.05).

CONCLUSION

Surgical treatment did not lead to significant improvements in ABP in OSA children except in those with more severe disease. The improvement in BP was partially masked by the weight gain following surgery.

CLINICAL TRIAL REGISTRATION

The trial was registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn.

REGISTRATION NUMBER

ChiCTR-TRC-14004131).

Ambulatory Blood Pressure Variability after Adenotonsillectomy in Childhood Sleep Apnea

OBJECTIVE

To investigate the influence of adenotonsillectomy (T&A) on ambulatory blood pressure (BP) variability in children with obstructive sleep apnea (OSA).

STUDY DESIGN

Prospective, interventional study.

METHODS

Children with OSA symptoms were recruited from a tertiary center. After OSA diagnosis was confirmed (ie, apnea-hypopnea index [AHI] > 1), these children underwent T&A for treatment. We performed polysomnography and 24-hour recordings of ambulatory BP before and 3 to 6 months postoperatively. Ambulatory BP variability was presented as the standard deviation of mean blood pressure in the 24-hour monitoring of ambulatory BP. Differences in BP variability among different subgroups were tested using a multivariable linear mixed model.

RESULTS

A total of 190 children were enrolled (mean age: 7.8 ± 3.3 years; 73% were boys; 34% were obese). The AHI significantly decreased from 12.3 ± 17.0 to 2.7 ± 5.5 events/hr after T&A. Overall, daytime, and nighttime ambulatory BP did not significantly change postoperatively, and overall, daytime, and nighttime ambulatory BP variability did not differ significantly preoperatively and postoperatively. In the subgroup analysis, children aged <6 years demonstrated a significantly greater decrease in ambulatory BP variability postoperatively than those aged >6 years (nighttime diastolic BP variability: 9.9 to 7.7 vs. 8.9 to 9.4). Children with hypertension also showed a significantly greater decrease in ambulatory BP variability than those without hypertension.

CONCLUSIONS

We concluded that overall ambulatory BP variability does not significantly change after T&A in children with OSA. Moreover, young-aged and hypertensive children demonstrate a significant decrease in BP variability after T&A.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:2491-2497, 2022.

Prevalence of High Blood Pressure in Pediatric Patients with Sleep-Disordered Breathing, Reversibility after Treatment: The KIDS TRIAL Study Protocol

Current data support an increase in the prevalence of high blood pressure (HBP) in pediatric patients with sleep-disordered breathing (SDB). Adeno-tonsillectomy has been shown to be an effective treatment for most patients. Our objective was to determine the prevalence of HBP in pediatric patients with SDB and the impact of adeno-tonsillectomy with a multicenter, longitudinal, and prospective study that included 286 children referred for suspected SDB. The diagnosis of SDB was established by polysomnography (PSG) and the diagnosis of HBP by 24-h ambulatory blood pressure monitoring (ABPM). In patients without SDB and SDB without treatment indication, these tests were repeated six months after the baseline visit. For patients with medical treatment for SDB, the tests were repeated six months after the treatment initiation. Finally, in patients with surgery indication, ABPM was performed just before surgical treatment and ABPM and PSG six months after the intervention. The study contributes to elucidating the association between SDB and HBP in pediatric patients. Moreover, it contributes to determining if intervention with adeno-tonsillectomy is associated with BP reduction. The results have direct implications for the management of SDB, providing essential information on treatment indications for existing clinical guidelines. NCT03696654.

Predictors of overnight postoperative respiratory complications in obese children undergoing adenotonsillectomy for obstructive sleep apnea

OBJECTIVES

Current clinical guidelines from the American Academy of Otolaryngology Head & Neck Surgery (AAO-HNS) recommend a preoperative polysomnogram (PSG) for obese patients prior to adenotonsillectomy (T&A). An overnight admission is recommended for children with severe (AHI >10) obstructive sleep apnea (OSA), citing a higher incidence of post-operative respiratory complications (PRCs) and need for respiratory support. Routine admission of obese children based on AHI >10 alone after T&A may place undue strain on hospital resources and increase healthcare costs, especially considering that many of these children have uncomplicated postoperative courses. In this study, we sought to identify variables from the pre-operative PSG and post-anesthesia care unit (PACU) that could more accurately predict overnight PRCs and indicate the need for a post-surgical admission after T&A.

METHODS

A single-center retrospective chart review was performed on a cohort of 155 obese children who underwent adenotonsillectomy for OSA. Inclusion criteria included patients 17 years of age and younger who had BMI 95th percentile or greater, underwent preoperative polysomnography, and were admitted overnight after T&A. Overnight respiratory complications were defined as an O₂ desaturation under 92%, the need for overnight airway support, a respiratory support regression, respiratory depression, and bronchospasm/laryngospasm. Multivariable binary logistic regression analysis, point-biserial correlation, and Chi-square tests were performed to assess relationship of BMI z-score, polysomnography parameters, and PACU events with overnight respiratory complications.

RESULTS

Lower O₂ saturation nadirs on polysomnography were an independent predictor of respiratory complications overnight (OR = 0.953, 95% CI = 0.91-0.99, P = 0.021), as was sleep time with O₂ saturation less than 90% (OR = 1.04, 95% CI = 1.00-1.07, P = 0.048). A prediction model with preoperative and postoperative variables significant on simple logistic regression yielded a ROC curve with AUC 0.89 (95% CI 0.82, 0.96). At a cutoff point of O₂ saturation nadir less than 80%, overnight PRCs were predicted with 70.8% sensitivity and 75.2% specificity. At a cutoff point of greater than 0.5% of sleep time spent with O₂ < 90% on PSG, overnight PRCs were predicted with 82.6% sensitivity and 62% specificity. Obstructive apneas (OAI) was not predictive of PRCs. BMI percentile was not significantly correlated with overnight respiratory complications, but BMI z-score was significantly correlated with overnight respiratory depression and an overnight airway event.

CONCLUSIONS

O₂ saturation nadir on PSG and time spent with oxygen saturation <90% (TST90) on PSG were found to be independent predictors of overnight postoperative respiratory complications after adenotonsillectomy in obese children. In addition to reaffirming existing guidelines for postoperative admission of patients with O₂ saturation nadir on PSG <80%, these findings also suggest considering postoperative admission for obese patients who experience >0.5% sleep time with O₂ sat <90% during PSG due to increased risk of overnight postoperative respiratory complications.

Office Blood Pressure Monitoring in Children with Obesity and Obstructive Sleep Apnea

OBJECTIVE

To investigate the relative contributions of obesity and obstructive sleep apnea (OSA) to unfavorable blood pressure in children.

STUDY DESIGN

Children aged 3-18 years with OSA-related symptoms were recruited. All children underwent office blood pressure (BP) monitoring and full-night polysomnography. Obesity was defined as a body mass index ≥95th percentile. OSA severity was divided into primary snoring (apnea-hypopnea index [AHI] <1), mild OSA (5> AHI ≥1), and moderate to severe OSA (AHI ≥5). Age- and sex-adjusted logistic regression analysis was performed to determine the associations among OSA, obesity, and elevated BP.

RESULTS

This cross-sectional study enrolled 1689 children (66% boys), with a mean age of 7.9 years. Compared with children with primary snoring, children with moderate to severe OSA had significantly higher systolic BP (108.1 mmHg vs 105.6 mmHg), diastolic BP (75.0 mmHg vs 70.4 mmHg), systolic BP percentile (75.0 vs 70.4), and diastolic BP percentile (74.0 vs 69.2). The rate of unfavorable BP (ie, elevated BP or hypertension level BP) also was significantly higher in children with more severe OSA. Children with obesity had higher BP and BP percentile. Logistic regression analysis revealed that children with obesity and moderate to severe OSA have a 3-fold greater risk of unfavorable BP compared with children without obesity and primary snoring.

CONCLUSIONS

We identified a 3-fold greater risk of unfavorable BP in children with obesity and moderate to severe OSA.

Changes in Cone-Beam Computed Tomography Pediatric Airway Measurements After Adenotonsillectomy in Patients With OSA

Importance

Early intervention using cone-beam computed tomography (CBCT) and adenotonsillectomy for children with obstructive sleep apnea (OSA) may prevent impaired growth, adverse cardiovascular consequences, learning deficits, and poor quality of life.

Objective

To assess changes in CBCT airway measurements and polysomnography (PSG) parameters that occur after adenotonsillectomy in children with OSA and to determine whether CBCT changes are correlated with apnea-hypopnea index (AHI) reduction.

Design, Setting, and Participants

This prospective cohort study was conducted at a tertiary medical center from 2013 to 2016. Children aged 7 to 13 years with PSG-confirmed OSA (ie, AHI ≥1) were recruited. Data analysis was performed from March to July 2021.

Exposures

All participants underwent CBCT and PSG before and after adenotonsillectomy.

Main Outcomes and Measures

Changes in PSG and CBCT parameters after adenotonsillectomy were analyzed.

Results

A total of 49 children (mean [SD] age, 9.5 [1.8] years; 34 boys [69.4%]) were recruited. Eighteen participants (36.7%) had obesity. After adenotonsillectomy, AHI significantly decreased from 11.4 to 1.2 events per hour (mean difference, -10.24 events per hour; 95% CI, -13.84 to -6.64 events per hour). The following CBCT parameters significantly increased: total airway volume (from 11 265 to 15 161 mm3; mean difference, 3896.6 mm3; 95% CI, 2788.0 to 5005.2 mm3), nasopharyngeal volume (from 2366 to 3826 mm3; mean difference, 1459.7 mm3; 95% CI, 1122.9 to 1796.5 mm3), minimal nasopharyngeal airway area (from 128 to 191 mm2; mean difference, 63.1 mm2; 95% CI, 47.4 to 78.8 mm2), mean nasopharyngeal airway area (from 144 to 231 mm2; mean difference, 86.8 mm2; 95% CI, 67.0 to 106.5 mm2), oropharyngeal volume (from 8898 to 11 335 mm3; mean difference, 2436.9 mm3; 95% CI, 1477.0 to 3396.8 mm3), minimal oropharyngeal airway area (from 82 to 158 mm2; mean difference, 76.2 mm2; 95% CI, 57.0 to 95.4 mm2), and mean oropharyngeal airway area (from 182 to 234 mm2; mean difference, 52.5 mm2; 95% CI, 33.6 to 71.4 mm2). Among all parameters, only body mass index percentile showed large effect size between the group with residual OSA (postoperative AHI ≥1) and the group with resolved disease, with the residual OSA group having a higher body mass index percentile (87.8 vs 61.4; mean difference, 26.33; 95% CI, 10.00 to 42.66). A quantile regression model revealed that total airway volume and minimal oropharyngeal airway area were significantly correlated with reductions in AHI.

Conclusions and Relevance

These findings suggest that in children undergoing adenotonsillectomy, improvements in total airway volume and oropharyngeal minimal airway area were correlated with reduction of AHI. Future studies are needed to assess whether CBCT has a role in the evaluation of children with OSA who are being considered for adenotonsillectomy.

Sleep-Disordered Breathing and Cardiovascular Disease in Children and Adolescents: A Scientific Statement From the American Heart Association

Obstructive sleep apnea (OSA) is a known risk factor for cardiovascular disease in adults. It is associated with incident systemic hypertension, arrhythmia, stroke, coronary artery disease, and heart failure. OSA is common in children and adolescents, but there has been less focus on OSA as a primary risk factor for cardiovascular disease in children and adolescents. This scientific statement summarizes what is known regarding the impact of sleep‐disordered breathing and, in particular, OSA on the cardiovascular health of children and adolescents. This statement highlights what is known regarding the impact of OSA on the risk for hypertension, arrhythmia, abnormal ventricular morphology, impaired ventricular contractility, and elevated right heart pressure among children and adolescents. This scientific statement also summarizes current best practices for the diagnosis and evaluation of cardiovascular disease–related complications of OSA in children and adolescents with sleep apnea and highlights potential future research in the area of sleep‐disordered breathing and cardiovascular health during childhood and adolescence.

C-reactive protein in children with obstructive sleep apnea and effects of adenotonsillectomy

OBJECTIVE

C-reactive protein (CRP) is an important serum marker of inflammation associated with cardiovascular outcomes. This study aims to evaluate the association between CRP and childhood obstructive sleep apnea (OSA) and clarify the effects of adenotonsillectomy on serum CRP levels in children with OSA.

METHODS

Children with symptoms suggestive of OSA who underwent an overnight polysomnography were recruited from a tertiary medical center. Their serum CRP levels were measured. For children who underwent adenotonsillectomy for OSA treatment, polysomnography and serum high-sensitivity CRP (hs-CRP) level measurement were conducted after surgery.

RESULTS

This study included 326 children (mean age: 7.2 ± 3.0 years; boys: 67%). Children with apnea-hypopnea index (AHI) > 5 events/h had significantly higher hs-CRP levels than children with AHI of 1-5 events/h and AHI < 1 event/h [median (interquartile range): 0.08 (0.03-0.25) vs 0.03 (0.02-0.14) vs 0.04 (0.01-0.10), P < 0.001]. Log-transformed hs-CRP levels were positively associated with log AHI values (r = 0.2, P < 0.001). In multiple linear regression analysis, hs-CRP levels were independently associated with AHI; 101 children with OSA (ie, AHI > 1) underwent adenotonsillectomy. In children with OSA in the study cohort, a significant reduction of hs-CRP levels did not occur after surgery [from 0.07 (0.02-0.22) to 0.08 (0.03-0.17), P = 0.716]. In children with OSA having abnormal hs-CRP levels (ie, CRP > 1 mg/dL), hs-CRP levels significantly decreased after surgery [from 1.87 (1.11-2.78) to 0.20 (0.07-1.04), P = 0.043].

CONCLUSION

Children with OSA had increased hs-CRP levels. Children with OSA and abnormal hs-CRP levels exhibited significantly reduced hs-CRP levels following adenotonsillectomy.

Effect of adenotonsillectomy on blood pressure in children with obstructive sleep apnea: a meta-analysis

BACKGROUND

While adenotonsillectomy (T&A) is widely recognized as the first-line therapy for pediatric obstructive sleep apnea (OSA), effects of T&A on blood pressure (BP) remain unclear. This meta-analysis evaluates the associations between T&A and BP in children with OSA.

METHODS

The study protocol was registered on PROSPERO (CRD42020154425). Two authors independently searched the PubMed, Medline, EMBASE, and Cochrane databases. The keywords used were "sleep apnea syndromes," "adenotonsillectomy," and "child." A random-effects model was applied to determine office systolic BP (SBP), diastolic BP (DBP), and ambulatory BP changes.

RESULT

Twelve studies with 1193 children were analyzed (mean age: 7.6 y; 54% boys). The apnea-hypopnea index significantly reduced of 9.4 events/h (95% CI, -12.0 to -6.8) after T&A. Office SBP (-0.24 mmHg; 95% CI, -1.64 to 1.16) and DBP (-1.65 mmHg; 95% CI, -3.47 to 0.17) did not decrease significantly after surgery. No significant decreases were observed in 24-h ambulatory BP after T&A. Subgroup analysis showed a significant postoperative decrease in office SBP (-6.23 mmHg; 95% CI, -7.78 to -4.67) and DBP (-7.93 mmHg; 95% CI, -10.37 to -5.48) among children with hypertension but a slight increase in office SBP (2.50 mmHg; 95% CI, 1.14 to 3.86) and DBP (1.98 mmHg; 95% CI, -0.02 to 3.98) in those without (P for heterogeneity < 0.001).

CONCLUSION

This meta-analysis suggests the office and ambulatory BP changes after T&A in children with OSA are trivial. Moreover, children with hypertension experience a significantly greater decrease in office BP than children without hypertension.

24-Hour Ambulatory Blood Pressure Variability in Children with Obstructive Sleep Apnea

OBJECTIVE

To evaluate blood pressure (BP) variability in 24-hour ambulatory BP monitoring in children with obstructive sleep apnea (OSA).

STUDY DESIGN

Case series study.

METHODS

Children aged 4 to 16 years with clinical symptoms were recruited in a tertiary medical center. Overnight polysomnography and 24-hour recordings of ambulatory BP were performed for each child. The severity of OSA was classified as primary snoring (apnea-hypopnea index [AHI] < 1), mild OSA (1 ≤ AHI < 5), moderate OSA (10 > AHI ≥ 5), and severe OSA (AHI ≥ 10). The standard deviation of mean BP was used as an indicator of BP variability.

RESULTS

A total of 550 children were included (mean age: 7.6 years; 70% were boys; 20% were obese). Compared with the children with primary snoring, children with severe OSA exhibited significantly higher nighttime systolic BP (108.0 vs. 100.5 mmHg, P < .001), nighttime diastolic BP (58.9 vs 55.6 mmHg, P = .002), nighttime mean arterial pressure (75.3 vs. 70.5 mmHg, P < .001), nighttime systolic BP load (40.5% vs. 25.0%, P < .001), nighttime diastolic BP load (25.3% vs. 12.9%, P < .001), and nighttime systolic BP variability (11.4 vs. 9.6, P = .001). Multiple linear regression analyses revealed an independent association between AHI and nighttime systolic BP variability (regression coefficient = 0.31, 95% CI = 0.06-0.56, P = .015) after adjustment for age, gender, adiposity, and hypertensive status.

CONCLUSIONS

OSA in children is associated with increased BP and BP variability.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2126-2132, 2021.

Obstructive sleep apnoea in adult patients post-tonsillectomy

BACKGROUND

The impact of removing the upper airway lymphoid tissue and in particular, tonsillectomy, in adults with OSA has not been demonstrated in large populations.

AIMS

To compare the severity of OSA and the prevalence of cardiovascular, metabolic and respiratory co-morbidities between patients with OSA who had undergone previous tonsillectomy and those who had not.

METHODS

The 19,711 participants in this study came from the European sleep apnea database (ESADA) which comprises data from unselected adult patients aged 18-80 years with a history of symptoms suggestive of OSA referred to sleep centers throughout Europe.

RESULTS

There were no differences between the two groups in terms of sex ratio and age (146 patients with previous tonsillectomy vs. 19565 patients without). Patients who had undergone tonsillectomy had a lower body mass index (29.3 ± 5.2 kg/m² vs 32.2 ± 6.6 kg/m², p < 0.001), lower subjective sleep latency (17.1 ± 17.8 min vs 25.5 ± 30.4 min, p = 0.001), lower ODI (15.7 ± 18.3 events/hour vs 30.7 ± 26.1 events/hour, p < 0.001), and SpO₂<90% time during sleep (21.8 ± 47.5 min vs 52.6 ± 80.8 min, p < 0.001). OSA patients with tonsillectomy had a lower prevalence of Type II diabetes mellitus (p = 0.001), hypertension (p < 0.001) and a higher prevalence of hyperlipidemia (p < 0.001) and were less likely to be commenced on CPAP (p < 0.001).

CONCLUSION

In a large population of almost 20,000 OSA patients from across Europe, patients who had undergone tonsillectomy presented with less severe OSA at time of diagnosis, and had a lower prevalence of Type II diabetes mellitus and cardiovascular co-morbidities.

Evaluation of Upper Airway in Children with Obstructive Sleep Apnea Using Cone-Beam Computed Tomography

OBJECTIVE

Cone-beam computed tomography (CBCT) offers three-dimensional structures in assessing upper airway of patients. This study aims to compare the cone-beam computerized tomography scan measurements between children with obstructive sleep apnea (OSA) and primary snoring.

STUDY DESIGN

Case-control study.

METHODS

This prospective study was conducted in a tertiary referral center. Thirty-six children with moderate-to-severe OSA (with apnea-hypopnea index [AHI] > 5 events/hour) and 36 age-, gender-, and obesity-matched children with primary snoring (AHI <1) were enrolled. The measurements in CBCT parameters were compared between children with moderate-to-severe OSA and primary snorers by conditional logistic regression model.

RESULTS

A total of 72 children (mean age, 7.9 ± 2.8 years; 64% male) were included. Children with moderate-to-severe OSA had a significantly smaller nasopharyngeal (2900 ± 1400 vs. 3800 ± 1800 mm³ , P = .017) and oropharyngeal airway volume (5600 ± 2700 vs. 7400 ± 4000 mm³ , P = .026) than those with primary snoring. Children with moderate-to-severe OSA, as compared to primary snorers, also had a significantly smaller minimal airway area in nasopharynx (77.4 ± 37.7 vs. 107.7 ± 52.0 mm² , P = .006) and oropharynx (66.6 ± 61.9 vs. 101.6 ± 65.8 mm² , P = .023). Moreover, the airway length was not significantly different between children with moderate-to-severe OSA and primary snoring.

CONCLUSIONS

The three-dimensional CBCT airway analysis could be used as a useful tool to evaluate upper airway in children with OSA.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:680-685, 2021.

Effect of Adenotonsillectomy on Ambulatory Blood Pressure in Pediatric Obstructive Sleep Apnea: 6-Month Follow-up Study

Objective

To investigate 24-hour ambulatory blood pressure changes 6 months after surgery among children with obstructive sleep apnea.

Study Design

Prospective interventional study.

Setting

Tertiary medical hospital.

Subjects and Methods

Children aged 4 to 16 years with symptoms of obstructive sleep apnea (apnea-hypopnea index >1) were recruited. All children underwent adenotonsillectomy and postoperative polysomnography overnight. The 24-hour ambulatory blood pressure was measured before and 6 months after surgery.

Results

The study cohort enrolled 124 children: mean (SD) age, 7.3 (3.1) years; 73% boys. After surgery, the apnea-hypopnea index significantly decreased from 13.3 (18.1) to 3.3 (7.2) events per hour ( P < .001). Overall systolic blood pressure and diastolic blood pressure were not significantly different following surgery, while daytime systolic blood pressure was slightly increased (114.3 to 117.3 mm Hg, P < .01) postoperatively. The hypertensive group (n = 43) exhibited significantly decreased levels of overall diastolic, nighttime systolic, and nighttime diastolic blood pressure ( P < .05), and 54% of hypertensive children became nonhypertensive after surgery. The nonhypertensive group (n = 81) showed slightly increased levels of nocturnal overall systolic, daytime systolic, and nighttime systolic blood pressure. A generalized linear mixed model revealed that children with hypertension had a greater decrease in systolic and diastolic ambulatory blood pressure during the daytime and nighttime (all P < .05) than those without hypertension.

Conclusions

Ambulatory blood pressure changes after adenotonsillectomy among children with obstructive sleep apnea are minimal. The decrease in ambulatory blood pressure after surgery is more prominent for hypertensive children than nonhypertensive children.

24-Hour Ambulatory Blood Pressure after Adenotonsillectomy in Childhood Sleep Apnea

OBJECTIVE

To assess the effects of adenotonsillectomy (T&A) on ambulatory blood pressure (ABP) in childhood obstructive sleep apnea (OSA).

STUDY DESIGN

From 2012 to 2017, children aged 4-16 years with symptoms and polysomnography-diagnosed OSA (apnea-hypopnea index [AHI] >1) underwent T&A. PSG studies and 24-hour ABP monitoring were performed before and at 3 months after surgery.

RESULTS

In total, 159 children were enrolled (mean age, 7.8 ± 3.3 years; 72% male). T&A significantly reduced the AHI from 12.4 ± 15.9 events/hour to 2.7 ± 5.7 events/hour (P < .001). A decrease was observed in the children's overall diastolic blood pressure (65.1 ± 6.1 mm Hg to 63.8 ± 7.4 mm Hg, P = .04) after surgery. In subgroup analysis, 100 (63%) patients were classified as nonhypertensive, and 59 (37%) were classified as hypertensive. Linear mixed model analysis revealed that compared with the children without hypertension, those with hypertension had superior improvement in systolic and diastolic blood pressure during daytime and nighttime (all P values < .01). The ABP changes after surgery were not correlated with the AHI changes. Finally, preoperative hypertension was an independent risk factor of postoperative hypertension among these children (OR 3.66; 95% CI 1.70-7.86).

CONCLUSIONS

Overall, in children with OSA, the 24-hour ABP change after T&A is small. However, among children with preoperative hypertension, there is significant BP improvement after T&A surgery.

Population-based survey of inpatient pediatric tonsillectomy and postoperative hemorrhage in Taiwan, 1997-2012

OBJECTIVE

Tonsil surgery in children is a common surgical procedure, and is mostly performed as an inpatient procedure in Taiwan. This study elucidates the epidemiology and postoperative hemorrhage of inpatient tonsillectomies in Taiwanese children.

METHODS

This study used the Taiwan National Health Insurance Research Database for analysis. From 1997 to 2012, all in-hospital children (aged <18 years) who underwent tonsillectomies were identified through the International Codes of Diseases (9th Revision). Incidence rates and trends of inpatient pediatric tonsillectomies during the study period were identified. Major complications, including readmission, reoperation, and mortality were identified. The factors associated with major complications were analyzed.

RESULTS

From 1997 to 2012, 17326 children received inpatient tonsillectomies (mean age, 8.6 ± 3.8 y; 65% boys). The overall incidence rate was 20.6 per 100,000 children. The incidence rate was highest in children who were 6-8 years of age, and boys exhibited a higher rate than girls (P < 0.001). Longitudinal data indicated that the incidence rate increased from 1997 (15.7/100,000 children) to 2012 (19.2/100,000 children) (P trend < 0.001). The proportions of readmission for any reason, readmission for bleeding, and reoperation were 1.8%, 0.9%, and 0.3%, respectively. No mortality occurred within 30 days of the tonsillectomy. A multivariable logistic model indicated that toddlers were associated with an increased risk of readmission for any reason (OR, 2.70; 95% CI 1.60-4.56), and adolescents were at risk of bleeding-related readmission (OR, 2.81; 95% CI 1.91-4.14) and reoperation (OR, 2.86; 95% CI 1.47-5.55). Children with comorbidities (OR, 3.14; 95% CI 1.93-5.09) or a surgical indication of tumor (OR, 11.73; 95% CI 4.93-27.91) had a higher risk of readmission. The use of nonsteroidal anti-inflammatory drugs or steroids is associated with an increased risk of readmission or reoperation. Moreover, concurrent procedures (i.e., adenoidectomy, ear surgery, or nasal surgery) did not increase the risk of readmission or reoperation.

CONCLUSIONS

The incidence rate and indications of obstructive sleep disorders for inpatient pediatric tonsillectomy increased during 1997-2012 in Taiwan. Postoperative readmission and reoperation were rare. Age, surgical indication, comorbidities, and drug administration were associated with readmission or reoperation in this study cohort.

Association of Adenotonsillectomy With Blood Pressure Among Hypertensive and Nonhypertensive Children With Obstructive Sleep Apnea

Importance

Hypertension in childhood may continue into adulthood and lead to adverse cardiovascular outcomes. Evidence suggests that adenotonsillectomy for childhood obstructive sleep apnea (OSA) may be associated with blood pressure (BP) improvement. However, how adenotonsillectomy is associated with BP in hypertensive and nonhypertensive children with OSA remains unclear.

Objective

To investigate disparities in BP changes after adenotonsillectomy in hypertensive and nonhypertensive children with OSA.

Design, Setting, and Participants

From January 1, 2010, to April 30, 2016, children (aged <18 years) with symptoms of OSA treated at National Taiwan University Hospital were enrolled in this retrospective case series study.

Interventions

Children underwent polysomnography for diagnosis of OSA (apnea-hypopnea index >1). All children with OSA underwent adenotonsillectomy.

Main Outcomes and Measures

Preoperative and postoperative overnight polysomnographic data were obtained. Office BP was measured in a sleep center before (nocturnal BP) and after (morning) polysomnography.

Results

A total of 240 nonobese children (mean [SD] age, 7.3 [3.0] years; 160 [66.7%] male and 80 [33.3%] female) with OSA were recruited. Postoperatively, the apnea-hypopnea index decreased significantly from 12.1 to 1.7 events per hour (95% CI of difference, -12.3 to -8.4 events per hour). The whole cohort had a significant decrease in nocturnal diastolic BP (66.9 to 64.5 mm Hg; 95% CI of difference, -4.1 to -0.7 mm Hg) and morning diastolic BP (66.9 to 64.4 mm Hg; 95% CI of difference, -4.2 to -0.8 mm Hg). The number (percentage) of patients with diastolic BP in the greater than 95th percentile decreased significantly nocturnally (48 [20.0%] to 33 [13.8%]; 95% CI of difference, -12.1% to -0.4%) and in the morning (52 [21.7%] to 34 [14.2%]; 95% CI of difference, -13.6% to -1.4%). Postoperatively, hypertensive children had a significant decrease in all BP measures, including mean (SD) nocturnal and morning systolic BP (nocturnal: 107.5 [8.6] mm Hg; morning: 106.0 [9.4] mm Hg), systolic BP index (nocturnal: -4.3 [8.6]; morning: -5.7 [8.5]), diastolic BP (nocturnal: 65.1 [11.5] mm Hg; morning: 64.4 [10.1] mm Hg), and diastolic BP index (nocturnal: -10.7 [17.3]; morning: -11.6 [15.7]), whereas the nonhypertensive group had a slight increase in nocturnal systolic BP (103.8 to 105.9 mm Hg; 95% CI of difference, 0.4-3.9 mm Hg). A generalized estimating equation model for subgroup comparisons revealed that children with hypertension, compared with those without, had greater improvement in all BP measures.

Conclusions and Relevance

Hypertensive children with OSA had a significant improvement in BP after adenotonsillectomy. Hypertensive children with OSA should be screened and treated by adenotonsillectomy because proper treatment not only eases OSA symptoms but also potentially prevents future cardiovascular and end-organ disease.

Combining MAD and CPAP as an effective strategy for treating patients with severe sleep apnea intolerant to high-pressure PAP and unresponsive to MAD

Introduction

This study aimed to determine the effect of combining positive airway pressure (PAP) therapy and mandibular advancement device (MAD) in patients with severe obstructive sleep apnea (OSA) who were pressure intolerant for PAP and were unresponsive to MAD.

Methods

This retrospective study reviewed the medical records of severe OSA patients with apnea-hypopnea index (AHI) ≥ 30/hr who were diagnosed between October 1, 2008 and June 30, 2014. Patients were initially treated with 2 weeks of PAP, and those who were intolerant to high-pressure PAP (≥15 cm H₂O) were switched to 12 weeks of MAD, which is a monobloc designed at 75% of maximum protrusion. Patients who had high residual AHI (≥15/hr) on MAD underwent 12 weeks of combination therapy (CT) with MAD and CPAP and were enrolled in the present study. Enrolled subjects who completed the 12-week CT were followed-up until June 30, 2016.

Results

A total of 14 male patients were included. All three treatments effectively reduced AHI, oxygen desaturation index (ODI), and total sleep time with SpO₂ <90% (% TST-SpO₂<90%) compared to pretreatment values. The residual AHI and ODI on CT was lower than that on MAD or PAP. The residual % TST-SpO₂<90% was lower than that on MAD and similar to that on PAP. The therapeutic pressure on CT was on average 9.2 cm H₂O lower than that on PAP. For the 11 patients who completed CT, only CT reduced ESS compared to pretreatment value. No treatment had significant impact on % slow wave sleep or overnight change of blood pressure. For patients who completed CT, the average usage was 5.9±1.7 hr/night at 12th week and 6.4±1.5 hr/night at a median follow-up of 36.5-months.

Conclusions

Combining MAD and CPAP showed additive effects on reducing AHI and ODI, and lowered the therapeutic pressures.

Sleep-disordered breathing is associated with blood pressure and carotid arterial stiffness in obese children

INTRODUCTION

Both sleep-disordered breathing (SDB) and high blood pressure (BP) occur more frequently among obese children than among normal weight children, and this may be due to endothelial dysfunction and worsened arterial stiffness. The aim of this study was to evaluate the possible association between SDB and BP, and the possible role of endothelial function and local and systemic arterial stiffness in a sample of obese children asymptomatic for sleep disturbances.

MATERIALS AND METHODS

Thirty-nine obese children were included in the study. Children underwent overnight limited channel polysomnography, and the vascular measurements included the following: office and 24-h ambulatory BP; brachial flow-mediated dilatation, carotid intima-media thickness and carotid distensibility measured using ultrasound; and systemic arterial stiffness index measured using digital volume pulse analysis.

RESULTS

Significant correlations between different BP measurements (both office and ambulatory BP monitoring and estimated by Z score) and SDB were found, including correlations involving the respiratory disturbance index, the apnea-hypopnea index (AHI), the number of desaturations per hour and the mean peripheral saturation (r ranging between 0.330 and 0.474). Carotid distensibility was correlated with the AHI (r = -0.367; P = 0.030) and with the mean oxygen saturation (r = 0.401; P = 0.017). In contrast, there was no relationship among flow-mediated dilatation, stiffness index, carotid intima-media thickness and all the tested respiratory markers. In the multivariate analysis, the supine Z SBP remained independently associated with the number of desaturations per hour and the AHI, even after correction for carotid distensibility and BMI.

CONCLUSION

Our data suggest that in obese children asymptomatic for sleep respiratory problems, SDB might worsen BP, in part, through an increase in arterial stiffness.

Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents

These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.

Lingual Tonsillectomy for Treatment of Pediatric Obstructive Sleep Apnea: A Meta-analysis

Importance

Evidence indicates correlations between lingual tonsil hypertrophy and pediatric obstructive sleep apnea (OSA). However, to our knowledge, a meta-analysis of surgical outcomes for lingual tonsillectomy in children with OSA has not been conducted.

Objective

To evaluate the therapeutic outcomes of lingual tonsillectomy for treatment of pediatric OSA.

Data Sources

The study protocol was registered on PROSPERO (CRD42015027053). PubMed, MEDLINE, EMBASE, and the Cochrane Reviews databases were searched independently by 2 authors for relevant articles published by September 2016.

Study Selection

The literature search identified English-language studies that used polysomnography to evaluate children with lingual tonsil hypertrophy and OSA after lingual tonsillectomy alone. The search keywords were lingual tonsil, lingual tonsillectomy, sleep endoscopy, sleep apnea, and child.

Data Extraction and Synthesis

Polysomnographic data from each study were extracted. A random-effects model pooled postoperative sleep variable changes and success rates for lingual tonsillectomy in treating pediatric OSA.

Main Outcomes and Measures

Four outcomes for lingual tonsillectomy were analyzed. These included net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum oxygen saturation, the overall success rate for a postoperative AHI less than 1, and the overall success rate for a postoperative AHI less than 5.

Results

This meta-analysis consisted of 4 studies (mean sample size, 18.25 patients), with a total of 73 unique patients (mean [SD] age, 8.3 [1.1] years). Fifty-nine percent (27 of 46) of the patients were male, and 1 of the 4 studies did not specify number of males. Lingual tonsillectomy was indicated for persistent OSA after adenotonsillectomy in all cases. Lingual tonsil hypertrophy was evaluated using computed tomography or magnetic resonance imaging in 1 study, sleep endoscopy in 2 studies, and cine magnetic resonance imaging in 1 study. The mean change in the AHI after lingual tonsillectomy was a reduction of 8.9 (95% CI, -12.6 to -5.2) events per hour. The mean change in the minimum oxygen saturation after lingual tonsillectomy was an increase of 6.0% (95% CI, 2.7%-9.2%). The overall success rate was 17% (95% CI, 7%-35%) for a postoperative AHI less than 1 and 51% (95% CI, 25%-76%) for a postoperative AHI less than 5. Postoperative complications that developed included airway obstruction, bleeding, and pneumonia.

Conclusions and Relevance

Lingual tonsillectomy is an effective surgical management for children with OSA caused by lingual tonsil hypertrophy, and it achieves significant improvement in the AHI and the minimum oxygen saturation. However, children frequently have residual OSA after lingual tonsillectomy, and postoperative complications must be carefully managed.

Upper airway surgery for obstructive sleep apnea reduces blood pressure

OBJECTIVES/HYPOTHESIS

To evaluate if upper airway surgery reduces blood pressure in patients with obstructive sleep apnea (OSA).

STUDY DESIGN

Prospective series.

METHODS

A prospective series of 112 consecutive OSA patients with hypertension (HTN). All patients were > 18 years old, respiratory disturbance index >5, all levels of apnea-hypopnea index (AHI), with a history of HTN treated with medication for at least 6 months. Surgical procedures included septoplasty, turbinate reduction, palate surgery, and tongue base reduction.

RESULTS

There were 92 men and 20 women, with a mean age of 48.6 years, mean body mass index (BMI) was 27.5 (range, 19.7-34.7). Mean follow-up was 16.1 months. The mean preoperative AHI was 32.6 (range, 1.2-104), with the mean lowest oxygen saturation (LSAT) of 79.9% (range, 52%-93%). The mean adjusted preoperative and postoperative systolic blood pressure (SBP) was reduced from 146 ± 15.3 mm Hg to 122 ± 12.5 mm Hg (P < .001), and diastolic blood pressure (DBP) was reduced from 91 ± 10.2 mm Hg to 76 ± 7.8 mm Hg (P < .001). There was a decrease in overall BMI from 27.5 ± 3.6 to 25.5 ± 3.0 (P < .001); however, based on multivariate analysis, the reduction in SBP and DBP was not affected by this BMI reduction. Fifty-eight patients (51.8%) did not require their antihypertensive after surgery. There was poor correlation noted between HTN with AHI, LSAT, and oxygen duration <90%.

CONCLUSIONS

Upper airway surgery does reduce SBP and DBP in patients with OSA.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:523-527, 2018.

Clinical and polysomnographic features of children evaluated with polysomnography in pediatric sleep laboratory

AIM

Sleep disordered breathing is a common problem in childhood that encompasses a spectrum of disorders extending from primary snoring to obstructive sleep apnea. This study aims to investigate the results of children undergoing evaluation with polysomnography in the sleep laboratory of a tertiary care hospital.

MATERIAL AND METHODS

Demographic and clinical features as well as sleep associated symptoms, scores of pediatric sleep questionnaire and Pittsburgh sleep quality index and polysomnography results are retrospectively evaluated.

RESULTS

Totally 131 patients were evaluated, of which 47.3% (n=62) were females and 52.7% (n=69) were males. Mean age was 101.85±59.15 months at the time of the study. Fifty percent (n=59) of patients complained of snoring and 43.7% (n=52) of patients complained of apnea during sleep. Mean obstructive hypopnea-apnea index was 5.12±11.72. Mean obstructive hypopnea-apnea index of snorers (6.93±13.53) was significantly higher than the mean obstructive hypopnea-apnea index of nonsnorers (2.32±5.43) (p=0.011). Mean obstructive hypopnea-apnea index of patients experiencing apnea during sleep (7.52±14.25) was significantly higher than the mean obstructive hypopnea-apnea index of the children who do not experience apnea (2.61±5.84) (p=0.008). No significant correlation was observed between obstructive hypopnea-apnea index and scores of pediatric sleep questionnaire and Pittsburgh sleep quality index. The prevalence of obstructive sleep apnea was 33.6% (n=44). Forty nine patients (39.8%) were treated after polysomnography. Frequently suggested treatment options were noninvasive mechanical ventilation (n=23, 46.9%), intranasal steroid (n=15, 30.6%), montelukast (n=11, 22.4%) and adenotonsillectomy (n=9, 18.4%).

CONCLUSIONS

Polysomnography is the gold standard in the diagnosis of sleep disordered breathing in children. Pediatricians should be able to recognize early signs and symptoms of sleep disordered breathing and refer the patients in risk to centers where evaluation with polysomnography is available.

Comparisons of Office and 24-Hour Ambulatory Blood Pressure Monitoring in Children with Obstructive Sleep Apnea

OBJECTIVE

To compare office blood pressure (BP) and 24-hour ambulatory BP (ABP) monitoring to facilitate the diagnosis and management of hypertension in children with obstructive sleep apnea (OSA).

STUDY DESIGN

Children aged 4-16 years with OSA-related symptoms were recruited from a tertiary referral medical center. All children underwent overnight polysomnography, office BP, and 24-hour ABP studies. Multiple linear regression analyses were applied to elucidate the association between the apnea-hypopnea index and BP. Correlation and consistency between office BP and 24-hour ABP were measured by Pearson correlation, intraclass correlation, and Bland-Altman analyses.

RESULTS

In the 163 children enrolled (mean age, 8.2 ± 3.3 years; 67% male). The prevalence of systolic hypertension at night was significantly higher in children with moderate-to-severe OSA than in those with primary snoring (44.9% vs 16.1%, P = .006). Pearson correlation and intraclass correlation analyses revealed associations between office BP and 24-hour BP, and Bland-Altman analysis indicated an agreement between office and 24-hour BP measurements. However, multiple linear regression analyses demonstrated that 24-hour BP (nighttime systolic BP and mean arterial pressure), unlike office BP, was independently associated with the apnea-hypopnea index, after adjustment for adiposity variables.

CONCLUSIONS

Twenty-four-hour ABP is more strongly correlated with OSA in children, compared with office BP.

Role of sleep quality in the metabolic syndrome

Emerging evidence has assigned an important role to sleep as a modulator of metabolic homeostasis. The impact of variations in sleep duration, sleep-disordered breathing, and chronotype to cardiometabolic function encompasses a wide array of perturbations spanning from obesity, insulin resistance, type 2 diabetes, the metabolic syndrome, and cardiovascular disease risk and mortality in both adults and children. Here, we critically and extensively review the published literature on such important issues and provide a comprehensive overview of the most salient pathophysiologic pathways underlying the links between sleep, sleep disorders, and cardiometabolic functioning.

Treatment outcomes of supraglottoplasty for pediatric obstructive sleep apnea: A meta-analysis

OBJECTIVE

To comprehensively review changes in sleep parameters and the success rate of supraglottoplasty for treating obstructive sleep apnea (OSA) in children. In particular, to elucidate treatment modalities and factors affecting treatment outcomes in children with both laryngomalacia and OSA.

METHODS

The study protocol was registered on PROSPERO (CRD42015027053). Two authors independently searched databases including PubMed, MEDLINE, EMBASE, and the Cochrane Review database. The keywords were "supraglottoplasty," "laryngomalacia," "OSA," "polysomnography," "child," and "humans." Supraglottoplasty served as the primary treatment for OSA or secondary treatment for persistent disease after previous surgeries. Subgroup analyses were conducted for children receiving supraglottoplasty as the primary or secondary treatment for OSA, and for children with and without comorbidities.

RESULTS

Eleven studies with 121 patients were analyzed (mean age: 3.7 years; 64% boys; mean sample size: 11 patients). After surgery, the mean differences between the pre- and postoperative measurements were a significant reduction of 8.9 events/h in the apnea-hypopnea index (AHI) and an increase of 3.7% in minimum oxygen saturation (MinSaO2; P < 0.05). The overall success rate was 28% according to a postoperative AHI <1 and 72% according to an AHI <5. Children receiving supraglottoplasty as the primary treatment had significantly younger ages (0.6 vs 6.4 years P < 0.001) than those receiving supraglottoplasty as the secondary treatment, but the outcomes were similar (33% vs 19% for a postoperative AHI < 1, P = 0.27; 77% vs 61% for a postoperative AHI < 5, P = 0.233). Moreover, children with comorbidities, compared with those without, had a similar success rate according to a postoperative AHI <1 (25% vs 21%, P = 0.805) and postoperative AHI <5 (62% vs 84%, P = 0.166).

CONCLUSIONS

Supraglottoplasty is an effective surgery for AHI reduction and MinSaO2 increase in children with OSA and laryngomalacia. However, complete resolution of OSA is not achieved in most cases, and factors affecting treatment outcomes in these children require future studies.

Polysomnographic findings after adenotonsillectomy for obstructive sleep apnoea in obese and non-obese children: a systematic review and meta-analysis

BACKGROUND

Use of polysomnography (PSG) is the gold standard of diagnosis and measurement of treatment effectiveness for paediatric obstructive sleep apnoea (OSA). Although adenotonsillectomy (T&A) is effective in diminishing the apnoea-hypopnoea index (AHI), a meta-analysis of postoperative changes for all other PSG parameters and outcome comparisons between obese and non-obese children following T&A have never been conducted.

OBJECTIVE OF REVIEW

To comprehensively review polysomnographic findings after surgery for obese and non-obese children with OSA.

SEARCH STRATEGY

Study protocol was registered on PROSPERO (CRD42013004737). Two authors independently searched databases including PubMed, MEDLINE, EMBASE and Cochrane Review from January 1997 to July 2014. The keywords used included the following: sleep apnea, OSA, sleep apnea syndromes, tonsillectomy, adenoidectomy, infant, child, adolescent, and Humans.

EVALUATION METHOD

A comprehensive systematic review and meta-analysis for literature for OSA children treated by T&A with polysomnography data. Random-effects model was applied to determine postoperative sleep parameter changes and the surgical success rate between obese and non-obese groups. The quality of studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

In total, 51 studies with 3413 subjects were enrolled. After surgery, sleep architecture was altered by a significant decrease in sleep stage 1, and an increase in slow-wave sleep and the rapid eye movement stage, and enhanced sleep efficiency. The mean difference between pre- and postoperative was a significant reduction of 12.4 event/h in AHI, along with a reduction of obstructive index, hypopnoea index, central index and arousal index. Mean and minimum oxygen saturation increased significantly after surgery. The overall success rate was 51% for postoperative AHI <1 (obese versus non-obese versus combined, 34% versus 49% versus 56%), and 81% for AHI <5 (obese versus non-obese versus combined, 61% versus 87% versus 84%). Meta-regression analyses demonstrate that postoperative AHI was positively correlated with AHI and body mass index z score before surgery.

CONCLUSIONS

Meta-analysis of current literature shows T&A offers prominent improvement in a variety of sleep parameters. Improvements in non-obese children exceeded those for obese children. Postoperative residual OSA remained in roughly half of the children, especially those with severe disease and obesity, making additional treatment strategies and/or long-term follow-up highly desirable.

Velopharyngeal Dysfunction and Sleep Apnea-A Survey to Ascertain Surgical Practice Patterns

OBJECTIVE

To determine if all cleft surgeons uniformly and adequately evaluate patients with cleft for obstructive sleep apnea (OSA) and consider OSA in treatment of velopharyngeal dysfunction (VPD).

DESIGN

A 22-question survey was administered via e-mail to 1117 surgeons who were members of the American Cleft Palate-Craniofacial Association. Logistic regression was used to determine if management was affected by years in practice, clinical volume, field of training, and region of practice.

MAIN OUTCOME MEASURES

We sought to determine if years in practice, clinical volume, region of practice, and surgical specialty affected surgeons' evaluation of OSA and their approaches to VPD.

RESULTS

A total of 231 surgeons responded (21% response rate), and 67% stated that they had trained in plastic surgery. With increasing years of practice, surgeons were less likely to refer patients for preoperative and postoperative sleep studies (P = .00 and P = .001, respectively), screen patients for sleep apnea (P = .008), or change their management based on a sleep study (P = .001). There were no significant differences in screening or testing for OSA based upon clinical volume. Among those surveyed, otolaryngologists were more likely to refer patients for postoperative sleep studies (P = .028). Surgeons in the Southeast were more likely to change their management based upon a sleep study (P = .038).

CONCLUSIONS

Statistically significant trends in screening and testing for OSA in the setting of VPD were identified by this survey. Notably, older surgeons were less likely to investigate OSA in their patients, and not all specialties equally refer for postoperative sleep studies.

Analysis of 24-Hour Ambulatory Blood Pressure Monitoring in Children With Obstructive Sleep Apnea: A Hospital-Based Study

In the present study, we aimed to verify associations between ambulatory blood pressure (ABP) and pediatric obstructive sleep apnea (OSA) in a hospital-based population. This was a cross-sectional observational study on children aged 4 to 16 years with OSA-related symptoms from a tertiary referral medical center. All children received overnight polysomnography and 24-hour recording of ABP. Severity of the disease was classified as primary snoring (apnea-hypopnea index, AHI <1), mild OSA (AHI 1-5), and moderate-to-severe OSA (AHI >5). For 195 children enrolled in this study (mean age, 7.8 ± 3.4 years; 69% boy), ABP increased as severity of OSA increased. During daytime, children with moderate-to-severe OSA had significantly higher systolic blood pressure (BP) (117.0 ± 12.7 vs 110.5 ± 9.3 mmHg), mean arterial pressure (MAP) (85.6 ± 8 .1 vs 81.6 ± 6.8 mmHg), and diastolic BP load (12.0 ± 9.6 vs 8.4 ± 10.9 mmHg) compared with children with primary snoring. During nighttime, children with moderate-to-severe OSA had significantly higher systolic BP (108.6 ± 15.0 vs 100.0 ± 9.4 mmHg), MAP (75.9 ± 9.6 vs 71.1 ± 7.0 mmHg), systolic BP load (44.0 ± 32.6 vs 26.8 ± 24.5 mmHg), systolic BP index (0.5 ± 13.1 vs -6.8 ± 8.5 mmHg), and higher prevalence of systolic hypertension (47.6% vs 14.7 %) compared with children with primary snoring. Multiple linear regression analyses revealed an independent association between AHI and nighttime systolic BP and MAP after adjusting for adiposity variables. This large hospital-based study showed that children with moderate-to-severe OSA had a higher ABP compared with children who were primary snorers. As elevated BP in childhood predicts future cardiovascular risks, children with severe OSA should be treated properly to prevent further adverse cardiovascular outcomes.